“Mental health apps offer a head start on recovery” – Irish Times, 18/01/18

Here is a piece by Sylvia Thompson on a recent First Fortnight panel discussion I took part in on apps in mental health.

Dr Séamus Mac Suibhne, psychiatrist and member of the Health Service Executive research technology team says that while the task of vetting all apps for their clinical usefulness is virtually impossible, it would be helpful if the Cochrane Collaboration [a global independent network of researchers] had a specific e-health element so it could partner with internet companies to give a meaningful rubber stamp to specific mental health apps.

“There is potential for the use of mental health apps to engage people with diagnosed conditions – particularly younger patients who might stop going to their outpatients appointments,” says Dr Mac Suibhne. However, he cautions their use as a replacement to therapy. “A lot of apps claim to use a psychotherapeutic approach but psychotherapy is about a human encounter and an app can’t replace that,” he says.

Here are some other posts from this blog on these issues:

Here is a post on mental health apps and the military.

Here is a general piece on evidence, clinical credibilty and mental health apps.

Here is my rather sceptical take on a Financial Times piece on smartphones and healthcare.

Here is a piece on the dangers (and dynamics) of hype in health care tech

Here is a post on a paper on the quality of smartphone apps for panic disorder.

#EHRPersonas – blogpost on CCIO site

Here is a post on the CCIO website on the recent EHR Personas workshop organised by eHealthIreland:

 

The HSE’s Chief Information Officer and the Clinical Strategy and Programmes Directorate are currently developing ‘Personas’ and ‘Scenarios’ to support the introduction of Electronic Health Records (EHR). As part of this project, a series of workshops for those working in the health services and also patients/service users was held on January 31stand February 1st.

One of the challenges of developing an EHR is capturing the diversity of needs it must address. Even a seemingly straightforward clinical setting will involve multiple interactions with multiple information sources. Contemporary mental health practice is focused on the community, but at the same time acute psychiatric units now co-located in acute general hospitals, and mental health issues very commonly arise simultaneously with general health needs, there is considerable overlap with the hospital system. Mental health services increasingly integrate multiple models of mental health, not only a purely medical one; while simultaneously safe psychiatric practice requires access to laboratory and imaging systems to the same degree as other medical disciplines.

Mental health services are therefore interacting with hugely complex information networks. Capturing all this complexity in a useful form is a considerable challenge. Personas and scenarios allow the expertise of patients and clinicians to be synthesised and for assumptions about what an EHR is for and can do to be challenged.

As a participant in a service provider workshop, I naturally enough was grouped with other mental health professionals. Most of our team were mental health nurses – in the community, delivering therapies and liaising with general hospital staff. We also had representation from pharmacy and administration, and myself as a psychiatrist. Other workshops include the diverse range of health professionals that make up a multidisciplinary community mental health team.
The service user persona was Tom, a 19 year old student from Mayo who has recently started university in Dublin. Tom’s friends notice he is more withdrawn and generally “not himself” and are sufficiently concerned to persuade him to attend the college health services where he sees a GP. There a physical examination, blood work and a urine drug screen are performed. A referral is made via HealthLink to a community mental health team. However a couple of nights later Tom becomes much more distressed and tells his friends he needs to escape from black-coated men following him everywhere. Tom’s friends bring him to the local Emergency Department where he is medically assessed and referred for a psychiatric opinion.

The scenario attempted to address how an EHR would address multiple issues that effect current mental health practice – from communication between primary care and mental health services to the avoiding duplication of investigations and of questioning.

One of the most persistent items of feedback from mental health service users is the initial contact with services involving much repetition of the same questions – often including biographical and demographic data – at a time of distress and anxiety.There is also frequently repetition of investigations and physical examinations, even when these have already been performed.

In our scenario, the situation developed with Tom deciding to move back home to Mayo and re-presenting to his local GP. This brought up a whole range of issues around the interaction between primary care, student health services, the mental health services across different catchment areas and regions. In our group, we discussed how the issue of access to the National Shared Record could play out with various permutations of consent from Tom, and the impact this could have on his care.

The second persona focused on a community mental health nurse, Ann, on her daily routine of calling to service users across a geographically dispersed mixed urban/rural area, engaging with clients at various stages of recovery, and administering treatments such as depot injections of antipsychotic medication and centrally dispensed medication such as clozapine. In our scenario we introduced features typical of remote working in an environment where mobile connections are not always reliable. Features such as the ability to work offline and upload updated records when back online were discussed.

In both service user and clinician scenarios, it became clear that if technology is to improve how health systems work for the benefit of the patient, it is in many ways by becoming invisible, by making the clinical interaction frictionless and about the person at its heart. The need for repeated, intrusive and unnecessary investigations – and questioning – could be reduced, allowing therapeutic interactions to take place unhindered. Both personas, and both scenarios, reinforced for me that the health system must have the service user – such as Tom – at its heart, and the delivery of healthcare is ultimately by people – such as Ann.

At its best, technology can enable this ultimately deeply personal interaction, rather than acting as another barrier, another “system” to be navigated.

Random thoughts on the media and healthcare

Every so often some one wonders aloud where there isn’t more good news reported. The BBC host Martyn Lewis , for instance, has been prominent in this, no doubt tired of having to read out news scripts full of doom and gloom during his career. Indeed, I discovered when looking up Martyn Lewis’ stance the site Positive News, which is all about Positive News.

And yet, the Daily Mail – which whatever else one can say, does not exactly put a positive, shiny, happy spin on the news – is the world’s most popular news website. We may say otherwise when asked, but we are drawn to the disastrous and doomy, or at least what can be portrayed as disastrous and doomy.

 

Someone – maybe Neil Postman – once observed that trust in media tends to erode dramatically when one considers the media coverage of something one actually knows about. If the media doesn’t get My Area right, why should I trust them on economics, or politics, or healthcare? This is even more pronounced in the current age where high-quality information on any technical topic is easily accessible with a little effort; the oft-lazy, unnuanced approach of much media. This is the other side of the clickbait we are drowning in.

In health care, there are a vast amount of interactions the vast majority of which are unremarkable or positive. Yet these don’t – and probably will never – get reported. Positive initiatives will get some media coverage  but this will be drowned out by controversy and scandal. This is the way of the world, and clearly has a role in ensuring good practice. One must also recognise, however, that this can distort our view not only of healthcare practice but of what we want to achieve. “Staying out of the papers” becomes an aim in itself, and leads to a reluctance to engage in any positive discourse for fear of being portrayed as pollyannaish or indifferent.

Interestingly, as a coda to these brief thoughts, consistently polls in Ireland find that doctors are the most trusted profession – in 2016 and in 2011. The comparative figures for other professions – especially the media and TDs – are interesting!

 

 

 

Thoughts on a Hackathon (Tribute)

I plan on continuing to use this blog mainly as an ongoing personal curation project, reviewing my prior medicine related writing and reflecting on my reaction to my former self’s writing. However, occasionally I may break cover and blog in a more “traditional” form.

I haven’t posted here in a few days, because I was in the wonderful city of Glasgow at the wonderful AMEE (Assocation for Medical Education in Europe) Hackathon. The official site of the hackathon is here  and it was organised by the wonderful Hack Partners 

I had a great time, and learned a lot. Here I have written a fairly reflective blog piece on the Hackathon, which contains a certain amount of rumination on the technology-health-education interface. None of this is intended as criticism of the Hackathon, AMEE, Elsevier or anyone else.

Yesterday evening I had (very little) time to kill between the end of the Hackathon and departing for the airport. It was a beautiful sunny evening by the Clyde (not a sentence one is used to reading) and I drafted some profound reflections for a blog post on the Hackathon. However, when I got to the airport and decided to write some more, the draft had disappeared. So this is an effort to replicate my thoughts.

The hackathon and me

I had come across the Hackathon via the AMEE mailing list, put my name forward listing my interest and being upfront about my lack of coding and upfront about my mix of enthusiasm and scepticism about technology’s role in healthcare (brief version: I’m enthusiastic about the positive changes technology can make to both, but sceptical of claims and promises of UTTER TRANSFORMATION BEYOND RECOGNITION)

There are a few disclaimers I should make about my personal Hackathon perspective, that perhaps disqualify me from being too dogmatic about the experience.
Firstly, I missed out on the all nighter element on the Saturday night. In my defence, at 36 with three children, a night’s sleep is one of the major attractions of a weekend away. For non-Hackathon reasons I had poor sleep the week leading up to Glasgow, and I had the option of staying in a hotel as family members were also around Glasgow. At 7 pm on Saturday I availed of the option to lie down for a couple of hours. 12 hours later, I awoke.

Secondly, I don’t use Facebook anymore, and it seems the Hackathon Facebook page was probably the best pre-Hackathon resource. As a neophyte Hackathoner, it would have been good to have done some networking prior and to have had a clearer idea about the structure (particular the pitches and team buildings)

Thirdly, for reasons I’ll discuss, I think our team was a little atypical of the Hackathon participants.

Fourthly, I don’t code, and possibly over the course of the Hackathon realised I’m not that much of a techie of any stripe. And while the Hackathon was welcoming to all, when it comes down to it the tech skills are the prized skills.

Pitching and team building

One aspect of the Hackathon was the initial pitch. I hadn’t intended to pitch, but at the last minute decided to talk about an idea I had a few years back – OSCEbuilder, essentially a way of automating much of the process of developing and running OSCE exams. It isn’t a very exciting idea, and it turned out that a) Dundee are using something like it anyway and b) a poster from NUI Galway at AMEE suggested that examiners actually take longer to examine with a tablet than the pen-and-paper. Not surprisingly, OSCEbuilder wasn’t very enticing to anyone much. I hadn’t even thought of it until five minutes before pitching, so I wasn’t exactly emotionally invested.

However in retrospect I do wish I had come up with a pitch prior to attending that I had some personal investment in – while it probably wouldn’t have been selected, it would have given me a starting point for involvement, rather than being to a certain degree passive in the process.
Anyhow, the pitchers than circulated around trying to get post-it notes from the other Hackathoners. The top 10 would become the nucleus of the team. This process slightly passed me by. In retrospect, I was overly self-conscious about not being able to code.

In ways our team ended up coalescing because none of us, except the original pitcher, had found a team before this. The pitchers idea was for “Ultrascan”, in brief a VR approach to training radiologists in ultrasound. The basic idea of simulation of ultrasound remained, but the focus shifted considerably from training radiologists to training healthcare workers in the developing world. In retrospect I think the technical challenge on our team was one of the most formidable (certainly in terms of getting a working demo in 24 hours) and this factor meant that the team was more about realising one team member’s vision rather than an overall team idea.

Feedback/Mentoring
The best hackathon moment for me was the mentoring from Prof John Sandars of the University of Sheffield  . We had quickly discovered that someone was doing more or less exactly what the pitch said http://www.medaphor.com/ and were kicking around various ideas on the Saturday morning. John Sandars instilled in us a sense of mission and of hope, and brought to our attention the massive need that ultrasound can meet in the developing world. On Saturday I learnt massively about the lack of access to ultrasound in African nations especially, and the preventable maternal mortality that results. I made contact with Kirsten deStigter of Imaging the World and read about the massive strides her organisation has made in address this issue. I am grateful for her extremely gracious response and I am hoping to further my knowledge of this issue.

There is an inherent arrogance in imagining that in a bit over 24 hours we could manage to solve the problem, especially when so many talented people are working on it already. However this gave us a focus, a sense of social mission, and the impetus to put together a pitch.

The feedback from Alejandro and River from HackPartners was also amazing. They managed to combine realistic, even harsh appraisal with an enthusiasm and encouraging attitude. I realised how tricky this kind of mentoring is. The world of startups and Hackathons is one which blends giddy, nearly manic enthusiasm and ambition with the most hard-nosed, querulous realism. One minute we are encouraged to dream big, to throw around words like “transform” and “revolutionise”, the next we are being closely questioned on just what our business model is. The HackPartners mentors (and the other mentors) were highly skilled at managing this.

Technology and practice

It is nearly a cliche in discussing tech and health (and tech and education) that the technology shouldn’t determine the clinical / educational use, but the clinical (or educational) need should determine the technology approach. I myself have pontificated along these lines  (Before going on, in this section I will use “healthcare” to encompass both clinical and medical-educational needs, otherwise this will all get even more unwieldy)

It was therefore richly ironic when it was I who, on the Saturday morning, was contributing to the team discussion words to the effect “let’s just get something together, and then we can think of the healthcare application.”

In the end, Prof Sandars’ intervention saved us from that possibility. However, this dynamic – of technology determining the healthcare use – is interesting. I reflected later that perhaps there is something subtler going on, if I – whose entire approach to this field is based on the idea that the technology must follow the educational/clinical need, rather than vice verse – was drawn into this line of thinking. The dynamic may be more than just a planning failure to consider or involve clinicians or teachers or service users, but more inherent to the tech/healthcare interface.

I don’t have an answer, even a half formed one, as to what this dynamic actually involves. One train of thought I’ve had involves the possibility that in the encounter between the technologist and the clinician, the technology is concrete, “practical”, while the clinical problem (in the context of this encounter) is something abstracted. I don’t mean that healthcare problems are “abstract” themselves. What I mean is this – all concerned are sitting round a table, laptops at the ready, and at that moment the healthcare problem is something abstract and disembodied. The technological aspects of the challenge become the practical, concrete thing that needs to be done – the healthcare need is abstracted and can therefore be shunted around as the practical technological work is done. The setting is technology-heavy – the laptop is the working tool. The healthcare scenario is abstract, remote.

These are very preliminary thoughts. Essentially the dynamic is more subtle than I previously thought, and perhaps more deeply embedded than I thought. I hesitate to say “inherent”, although I do suspect the cultural valorisation of technology contributes as well.

Would a hackathon located directly in a clinic, or a ED, or coordinated with a beside tutorial or somewhere where healthcare is actually happening, have a different dynamic? Would involving clinicians/teachers with little interest in technology, or even an overt hostility, actually make for a more rigorous dialectic? Or does something else have to happen?

Do “quiet” ideas get shunted aside?

The pitch is clearly a vital part of startup culture. A good pitch requires good discipline, and a clarity of thought about the product or service. Certainly the successful pitches at #ameehacks were both entertaining and informative. It was pretty clear the judges valued a working demo very highly.

I do wonder if quieter ideas can get shunted aside in pitch culture. TED talks are in many ways wonderful, but I have always been concerned that presenters that make a slick show and give the audience what they want can trump more difficult, more genuinely challenging, more meaningful ideas.

There is a tendency for healthcare startups to promise to UTTERLY TRANSFORM HEALTHCARE and education startups to REVOLUTIONISE HOW WE LEARN and so on. The quieter, smaller solution (and perhaps the genuinely revolutionary one) gets lost.

Closing thoughts

I would love to see a Hackathon in my own clinical field, mental health, involving service users as equal participants. I would love to see community hackathons spread. I would love to see the positivity, friendliness and warmth that I witnessed in hackathon culture become a model for wider engagement in ideas and practices. I would love to see hackathons where the hacks were not necessarily technological.

I will think and read a bit more about the interplay between technical innovation and education/clinical practice before further blogging. Any suggestions for reading are warmly welcomed.